3701-84-85
Quality assessment and performance improvement.

The provider of a pediatric cardiovascular surgery service
shall have a regular formal morbidity and mortality conference chaired by the
medical director of the pediatric cardiovascular surgery service or his/her
designee. Morbidity and mortality conferences shall be held at a minimum once a
month or more frequently depending on the need. All deaths and complications
such as reoperation for bleeding, deep sternal wound infection and stroke shall
be reviewed and any patterns that might indicate a problem shall be
investigated by the provider of the service and remedied if necessary.